Gingival Addition and Removal

The indications for gingival augmentation have chang-ed over the year’s from treatments of recession to achie-ving optimal esthetics.
While treatments of recession is still an objective, it can now be achieved with the introduction of new root coverage techniques. The objectives of gingival augmentation are to:

• Treat gingival recession
• Increase the width and thickness of the gingival
• Increase vestibular depth
• Cover exposed rood surfaces
• Plump edentulous ridges to receive pontics and improve soft tissue contours

• Recession and a minimal zone of attached gingival, usually less than 2 mm, which creates the risk of further recession. This can be minimized or avoided by creating a wider band of attached, keratinized tissue.
  
  
• Gingival augmentation is especially helpful in situations in which a change in the morphology of the mucogingival complex facilitates proper plaque control thereby eliminating gingival inflammation and sensitivity.

Figure 1. This patient presented with cosmetic concerns requiring gingival addition and removal. (see Figures 2 and 3 on page 2) Figure 2. A new provisional restoration guided the placement of connective tissue graft to the ideal gingival height. This was one of four different surgical appointments. Figure 3. The Final result was an esthetic periodontal-restorative apperance.

• The depth of the vestibule can be increased by placing a soft tissue graft in conjunction with apical positioning of the mucogingival complex.
• If restorative procedures that will enter the gingival crevice are planned, such as crown margins, an adequate amount of attached gingival (at least 2mm) is necessary it prevent gingival inflammation or recession around these restorations.
• Other restorative procedures such as removable partial dentures and over dentures can procedure a mechanical, inflammatory insult in areas of minimal keratinized gingival.
• Prominent tooth position or any orthodontic procedure that is likely co cause a bony dehiscence in the presence of a thin periodontium.
• Tooth movement, either by orthodontics or by the natural eruptive pattern, which will result in moving the tooth outside of the alveolar housing.
• It’s an interesting phenomenon that when teeth are moved lingually within the alveolar housing the zone of gingival increases.
• Masking dark root surfaces or metallic abutments of dental implants. Dental implants generally have a smaller proportion of attached gingival and larger proportion of free gingival compared with natural teeth. Consequently, the addition of thickened keratinized gingival may prevent an unesthetic result.
• Gingival augmentation can correct the appearance of a tooth which appears too long in relation ti the adjacent theeh by equalizing the app-earance of symmetry.

Surgical techniques to increase the width and thickness of the keratinized tissue are among the most predictable periodontal procedures.Gingival augmentation is most often accomplished by soft tissue grafting. Autografting procedures include free gingival, pedicle and subepithelial connective tissue grafting. Allograft material such as Alloderm (acellular dermal matrix) may also be used. All of these soft tissue grafts may be combined with biologic mediator such as Emdogain, platelet rich plasma (PRP) and platelet derived growth factors (PDGF) to enhanced the clinical result.

Blood supply and interproximal bone levels are the most significant concern in all of these grafting procedures. A case in point is the difficulty in covering a root which has no blood supply. Techniques to modify root contTechniques to modify root contours and enlarge the recipient bed are often used to overcome this problem. Tobacco use and uncontrolled diabetes are among the factors which compromise gingival blood supply and therefore are risk factors for obtaining optimal results in root coverage techniques. and predictability of gingival augmentation procedures will likely increase as well.

Gingival Removal

Gingival removal by gingivectomy or gingivoplaty is performed to treat the pathologic effects of periodontitis and other conditions that result in altera- tions in normal gingival form. While gingivectomy plays a lesser role in the current repertoire of available periodontal techniques, it still remains an effective form of treatment in certain clinical situations.

The objectives of gingival removal are to:

• Eliminate suprabony gingival pocket which persist after completion of initial periodontal therapy. Reduction or elimination of these pockets may facilitate the patient’s ability to maintain periodontal health.
• Create a more esthetic gingival form in cases of excessive gingival display. In many cases, alteration of the crestal bone level in conjunction with gingival removal may be necessary to maintain an adequate biologic width.

Figure 4. 6mm of recesion exposed this tooth root creating a cosmetic deformity and hypersensitive cementum. Figure 5. A connective tissue graft was placed to cover the root to the cemento-enamel junction. Figure 6. The final resul was full coverage of all previosly exposed cementum eliminating sensitivity and creating an esthetic appearance.

Figure 7. Altered passive eruption caused this patient's very gummy smile. Figure 8. Cosmetic ginfival removal exposed the anatomical crowns and created gingival harmony for an ideal smile line.

• Eliminate soft tissue craters resulting from periodontal disease.
• Reduce gingival enlargements such as Dilantin hyperplasia resulting from medications or generic factors.
• Create clinical crown length for restorative or endodontic purposes when ostectomy is not required to preserve the biologic width.

• The presence of interdental osseous craters and intrabony defects.
• The presence of large osseous ledges and exostoses which may leave bone exposed following removal of the gingival.
• When removal of the soft tissue would constitute an unacceptable cosmetic compromise.

Clinicians must be cautious in removing gingival in patients with a high caries rate so as not to expose tooth roots.

We hope this review of the rationale for gingival augmentation and subtraction has been helpful to you in treatment planning and determining the amount of gingival necessary for a predictable and desirable restorative outcome and the prevention of future disease.
We continue to analyze new clinical techniques being developed and incorporated into periodontal practice with our common goal of greater predictability and benefit for our patients.